ARCHETYPE Fundoscopic examination of eyes (openEHR-EHR-OBSERVATION.fundoscopic_examination.v0)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.fundoscopic_examination.v0
ConceptFundoscopic examination of eyes
DescriptionRecord of clinical findings on fundoscopy of eyes.
PurposeTo record details about clinical findings on fundoscopy of eyes.
ReferencesLamirel C, Bruce BB, Wright DW, Delaney KP, Newman NJ, Biousse V. Quality of nonmydriatic digital fundus photography obtained by nurse practitioners in the emergency department: the FOTO-ED study. Ophthalmology. 2012 Mar;119(3):617-24. doi: 10.1016/j.ophtha.2011.09.013. Epub 2012 Jan 3. PubMed PMID: 22218140; PubMed Central PMCID: PMC3294008.

Grading diabetic retinopathy from stereoscopic color fundus photographs--an extension of the modified Airlie House classification. ETDRS report number 10. Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology. 1991 May;98(5 Suppl):786-806. PubMed PMID: 2062513.

Li HK, Horton M, Bursell SE, Cavallerano J, Zimmer-Galler I, Tennant M, Abramoff M, Chaum E, Debuc DC, Leonard-Martin T, Winchester M; American Telemedicine Association Diabetic Retinopathy Telehealth Practice Recommendations Working Group., Lawrence MG, Bauman W, Gardner WK, Hildebran L, Federman J. Telehealth practice recommendations for diabetic retinopathy, second edition. Telemed J E Health. 2011 Dec;17(10):814-37. doi: 10.1089/tmj.2011.0075. Epub 2011 Oct 4. Review. PubMed PMID: 21970573.
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2008-07-27
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2008-07-27
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, references=Lamirel C, Bruce BB, Wright DW, Delaney KP, Newman NJ, Biousse V. Quality of nonmydriatic digital fundus photography obtained by nurse practitioners in the emergency department: the FOTO-ED study. Ophthalmology. 2012 Mar;119(3):617-24. doi: 10.1016/j.ophtha.2011.09.013. Epub 2012 Jan 3. PubMed PMID: 22218140; PubMed Central PMCID: PMC3294008. Grading diabetic retinopathy from stereoscopic color fundus photographs--an extension of the modified Airlie House classification. ETDRS report number 10. Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology. 1991 May;98(5 Suppl):786-806. PubMed PMID: 2062513. Li HK, Horton M, Bursell SE, Cavallerano J, Zimmer-Galler I, Tennant M, Abramoff M, Chaum E, Debuc DC, Leonard-Martin T, Winchester M; American Telemedicine Association Diabetic Retinopathy Telehealth Practice Recommendations Working Group., Lawrence MG, Bauman W, Gardner WK, Hildebran L, Federman J. Telehealth practice recommendations for diabetic retinopathy, second edition. Telemed J E Health. 2011 Dec;17(10):814-37. doi: 10.1089/tmj.2011.0075. Epub 2011 Oct 4. Review. PubMed PMID: 21970573., current_contact=Aitor Eguzkitza, Universidad Pública de Navarra - Complejo Hospitalario de Navarra, aitor.eguzkiza@unavarra.es, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=CA5A360446ED6A1B91293FA976C175D8, build_uid=23e01ad1-ea04-4677-ab3c-3e54df77881d, ip_acknowledgements=This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org., revision=0.0.1-alpha}
Keywords
Lifecyclein_development
UIDd8e13c17-6da2-40b7-b945-5f93df77daa4
Language useden
Citeable Identifier1013.1.208
Revision Number0.0.1-alpha
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Luis Serrano, Universidad Pública de Navarra (UPNA), lserrano@unavarra.es
José Andonegui, Hospital de Navarra, jose.andonegui.navarro@cfnavarra.es
Heather Leslie, Atomica Informatics, Australia, originalLanguage=en, translators=Portuguese (Brazil): Marco Borges, P2D, marco.borges@p2d.com.br
Spanish (Spain): Aitor Eguzkitza, Universidad Pública de Navarra - Complejo Hospitalario de Navarra, aitor.eguzkiza@unavarra.es
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  • Left eye [The left eye was examined.]
    [SNOMED-CT::362503005] (Entire left eye (body structure))
  • Right eye [The right eye was examined.]
    [SNOMED-CT::362502000] (Entire right eye (body structure))
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  • Direct [Study performed by direct ophthalmoscopy.]
  • Indirect [Study of eye fundus by indirect ophthalmoscopy method.]
  • Contact lens biomicroscopy [Eye fundus viewing through biomicroscopy lens in contact to patient's eye surface.]
  • Non-contact lens biomicroscopy [Eye fundus viewing through biomicroscopy lens without contact to patient's eye surface.]
  • Mydriatic retinography [Observation of retina through funduscopic images acquired by previous dilatation of patient's pupils.]
  • Non-mydriatic retinography [Observation of retina through funduscopic images acquired without previous dilatation of patient's pupils.]
  • Angiography [Observation of the eye fundus using a fluorescent dye inyected to emphasize the blood vessels in the eye retina.]
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openEHR-EHR-CLUSTER.device.v1 and specialisations
Exclude:
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  • 30º [30º angle used for small pupil (SP) capture (for patients with pupil diameter <3.3mm).]
  • 45º [45º angle used to acquire eye fundus of normal pupils.]
  • 60º [60º angle used to acquire eye fundus in some DR screening studies.]
  • 100º [Wide angle acquisition.]
  • 200º [Ultra-wide angle acquisition.]
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  • Study field 1 [*]
  • Study field 2 [*]
  • Study field 3 [*]
  • Study field 4 [*]
  • Study field 5 [*]
  • Study field 6 [*]
  • Study field 7 [*]

Runtime name constraint:
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  • Mosaic [Mosaic obtained from combining every peripheral acquisitions and the center one.]
  • Central [Image centered on the macula.]
  • Nasal [Image centered on the optic nerve or papila.]
  • Temporal [Image centered on the temporal quadrant of the retina.]
  • Superior [Image centered on the superior half of the retina.]
  • Inferior [Image centered on the inferior half of the retina.]
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2: Unable to exclude all emergent findings [*]
3: Only able to exclude emergent findings [*]
4: Quality not ideal, but is possible to exclude subtle findings [*]
5: Ideal quality [*]
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  • Direct [Study performed by direct ophthalmoscopy.]
  • Indirect [Study of eye fundus by indirect ophthalmoscopy method.]
  • Contact lens biomicroscopy [Eye fundus viewing through biomicroscopy lens in contact to patient's eye surface.]
  • Non-contact lens biomicroscopy [Eye fundus viewing through biomicroscopy lens without contact to patient's eye surface.]
  • Mydriatic retinography [Observation of retina through funduscopic images acquired by previous dilatation of patient's pupils.]
  • Non-mydriatic retinography [Observation of retina through funduscopic images acquired without previous dilatation of patient's pupils.]
  • Angiography [Observation of the eye fundus using a fluorescent dye inyected to emphasize the blood vessels in the eye retina.]
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openEHR-EHR-CLUSTER.device.v1 and specialisations
Exclude:
All not explicitly included archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0067], code=at0067, itemType=ELEMENT, level=2, text=Field angle, description=Describes the optical acceptance angle of the lens used during the test., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • 30º [30º angle used for small pupil (SP) capture (for patients with pupil diameter <3.3mm).]
  • 45º [45º angle used to acquire eye fundus of normal pupils.]
  • 60º [60º angle used to acquire eye fundus in some DR screening studies.]
  • 100º [Wide angle acquisition.]
  • 200º [Ultra-wide angle acquisition.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0072], code=at0072, itemType=ELEMENT, level=2, text=Attempts, description=Number of attempts before obtaining the acquisition (doesn't compute if test is repeated by a specific recognized technical failure)., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=1; max: <=3

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0073], code=at0073, itemType=CLUSTER, level=2, text=(Subdivision of the retina), description=Subdivision of the retina identifying eye fundus image locations., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Runtime name constraint:
Subdivision of retina [*], extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0073]/items[at0074], code=at0074, itemType=ELEMENT, level=3, text=(ETRDS fields), description=Subdivision of the retina based on Diabetic Retinopathy Study fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Study field 1 [*]
  • Study field 2 [*]
  • Study field 3 [*]
  • Study field 4 [*]
  • Study field 5 [*]
  • Study field 6 [*]
  • Study field 7 [*]

Runtime name constraint:
Diabetic Retinopathy Study field [*], extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0073]/items[at0082], code=at0082, itemType=ELEMENT, level=3, text=Mosaic and peripherals, description=Division of the retina in quadrants + mosaic obtained from the combination of them., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • Mosaic [Mosaic obtained from combining every peripheral acquisitions and the center one.]
  • Central [Image centered on the macula.]
  • Nasal [Image centered on the optic nerve or papila.]
  • Temporal [Image centered on the temporal quadrant of the retina.]
  • Superior [Image centered on the superior half of the retina.]
  • Inferior [Image centered on the inferior half of the retina.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0056], code=at0056, itemType=ELEMENT, level=2, text=Shadow artifact, description=True if shadow artifact is present on the border of the image., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: false, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0055], code=at0055, itemType=ELEMENT, level=2, text=Cataract artifact, description=True if cataract obstructs the visualization of eye fundus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: false, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0059], code=at0059, itemType=ELEMENT, level=2, text=Quality of visualisation, description=Levels quantifying the quality of each acquisition, based in the ease to visualize the structures on the eye fundus., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=1: Quality inadequate for any diagnostic purpose [*]
2: Unable to exclude all emergent findings [*]
3: Only able to exclude emergent findings [*]
4: Quality not ideal, but is possible to exclude subtle findings [*]
5: Ideal quality [*]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0058], code=at0058, itemType=ELEMENT, level=2, text=Visualisation description, description=Narrative description about visualisation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0123], code=at0123, itemType=ELEMENT, level=2, text=High refraction, description=True if the refraction of the eye exceeds the range from -12D to +15D., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: false, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0028]/items[at0144], code=at0144, itemType=SLOT, level=2, text=Extension, description=Additional information required to capture local content or to align with other reference models/formalisms., comment=For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
All not explicitly excluded archetypes, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]